Provider Demographics
NPI:1144077256
Name:TINE, FAYE M (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:FAYE
Middle Name:M
Last Name:TINE
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 BOTELLE MNR
Mailing Address - Street 2:
Mailing Address - City:CROMWELL
Mailing Address - State:CT
Mailing Address - Zip Code:06416-1301
Mailing Address - Country:US
Mailing Address - Phone:860-424-6792
Mailing Address - Fax:
Practice Address - Street 1:56 E MAIN ST
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3802
Practice Address - Country:US
Practice Address - Phone:860-271-0098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4690235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist